HOSPITAL MALNUTRITION IN VIET NAM: PREVALENCE, ASSOCIATED RISK FACTORS AND APPROPRIATE SCREENING TOOLS

Malnutrition among hospitalised patients is considered one of the most common and significant health issues in acute care settings worldwide. Studies have shown that it is associated with many adverse outcomes during and after hospitalisation, such as increased physical impairments, comorbidities, hospital length of stay, readmissions, hospital costs, mortality, and decreased quality of life. It has been the focus of research and strategy implementation in highincome countries over the last few decades. However, in Viet Nam, a lower middleincome country, malnutrition in hospitalised patients has been a low priority given previous pressing public health issues, such as communicable diseases, malnutrition in the community, and micronutrient deficiencies. Similarly, the focus on nutrition, dietary intake, and meal provisioning within the hospital system in Viet Nam has also been given limited attention. As a result, recommendations for hospital malnutrition prevention and treatment measures are limited, including recommendations for the most appropriate nutrition screening tools to be implemented. The prevalence of malnutrition in adults within the community has recently decreased significantly, with overweight, obesity, and noncommunicable diseases increasing leading to a higher demand for hospital use.

H OSPITAL M ALNUTRITION I N V IET N AM :

Tran Quoc Cuong Doctor of Medicine, Master of Medical Sciences

Submitted in fulfilment of the requirements for the degree of

Doctor of Philosophy

School of Exercise and Nutrition Sciences

Faculty of Health Queensland University of Technology, Australia

2018

Keywords

Malnutrition, Hospital, Acute Care Setting, Prevalence, Subjective Global Assessment (SGA), Viet Nam, Nutrition Screening Tool, Validity, Reliability, Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Nutrition Risk Screening (NRS-2002), Mini Nutrition Assessment Short Form (MNA-SF), Body Mass Index (BMI), Foodservices, Ho Chi Minh City, Associated Risk Factors, Dietary Intake, Feasibility, Acceptability, Malnourished, Patients, Underweight, Lower Middle Income Country, Southeast Asia, Medical Doctor

Abstract

Malnutrition among hospitalised patients is considered one of the most common and significant health issues in acute care settings worldwide Studies have shown that it is associated with many adverse outcomes during and after hospitalisation, such as increased physical impairments, co-morbidities, hospital length of stay, readmissions, hospital costs, mortality, and decreased quality of life It has been the focus of research and strategy implementation in high-income countries over the last few decades However, in Viet Nam, a lower middle-income country, malnutrition in hospitalised patients has been a low priority given previous pressing public health issues, such as communicable diseases, malnutrition in the community, and micronutrient deficiencies Similarly, the focus on nutrition, dietary intake, and meal provisioning within the hospital system in Viet Nam has also been given limited attention As a result, recommendations for hospital malnutrition prevention and treatment measures are limited, including recommendations for the most appropriate nutrition screening tools to be implemented The prevalence of malnutrition in adults within the community has recently decreased significantly, with overweight, obesity, and non-communicable diseases increasing leading to a higher demand for hospital use

This research provides evidence to assist the Vietnamese Government and health authorities to develop and implement appropriate policies, guidelines, and recommendations related to nutrition screening and meal provisioning in hospitals in the Vietnamese context This is especially important, as improvement of health care services and infrastructure is currently on the political agenda, including the establishment and improvement of nutrition and dietetic services

This research consists of three studies The first study aims to determine the prevalence of malnutrition and the associated risk factors for hospital malnutrition in Viet Nam The second study aims to investigate the dietary intake characteristics among hospitalised adults in acute care setting in Viet Nam The third study aims to determine the most appropriate nutrition screening tool for use in adults in acute care settings within the Vietnamese context The first and second studies were conducted

at the same time with the same participants (n=888) from six general public hospitals

iv Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools

in Ho Chi Minh City, Viet Nam using a cross-sectional survey in April and May

2016 The first study assessed the nutritional status and medical and socio-economic status of participants through physical examination and a review of their medical records, while the second study assessed the dietary intake of the participants using the 24-hour dietary recall method Based on the results of the first study, the third study (a prospective validation study) was conducted in May 2017 in three general public hospitals in Ho Chi Minh City with a sample of adult patients (n=150) and medical doctors (n=40) All of the studies were implemented with the support from Nutrition Centre in Ho Chi Minh City, Viet Nam

Four papers resulted from this research Paper One describes the prevalence and associated risk factors of malnutrition among hospitalised adults in Viet Nam Paper Two describes the characteristics of dietary intake among hospitalised adults in Viet Nam Paper Three presents the validity of four nutritional screening tools: Nutrition Risk Screening (NRS-2002), Malnutrition Screening Tool (MST),Malnutrition Universal Screening Tools (MUST), and Mini Nutrition Assessment Short Form (MNA-SF), against Subjective Global Assessment (SGA) for inpatient adults in Viet Nam Finally, Paper Four presents the validity, reliability, and feasibility of nutrition screening tools NRS-2002 and MST administered by medical doctors in Viet Nam

The findings of this research show malnutrition among hospitalised adults in acute care setting to be a significant health problem in Viet Nam, with a prevalence

of 34.1% Hospital malnutrition was not only associated with clinical characteristics, such as longer length of stay with OR:1.6 (1.1-2.2); admitted via emergency with OR:1.5 (1.0-2.4); higher in some medical conditions, such as oncology (46.5%) and pulmonary (43.6%); and higher in level one hospitals (37.1%); it was also found to

be associated with the socio-economic status of the patient, including poverty and marginal poverty household status (OR: 1.6 (1.0-2.4) and 1.3 (1.0-1.5), respectively), and employment status (for persons who did not or omitted work in the last six months) with OR:1.7(1.0-2.9)

One other important risk factor for malnutrition is dietary intake, and this research is the first of its kind to explore hospital dietary intake in a lower middle-income country setting in the Southeast Asia region The study found that patients in Viet Nam with a low dietary intake were more likely to be malnourished compared

to patients who were well-nourished with OR:2.2 (1.3-3.7).The majority of participants had low dietary intake (mean energy intake 850 Kcal/day or 3550 kJ/day), and only a very small number (4.2%) met their nutritional requirements (35Kcal/ideal body weight) The main contributors to the low dietary intake of hospitalised patients in Viet Nam included the number of meal occasions (with patients/participants consuming 3-4 meals(including snacks)/day and 5-6 meals/day with an OR of 0.08 (0.03-0.28) and 0.14 (0.05-0.40) compared to participants with ≤

2 meals/day), having food restrictions (for example, for medical reasons, with OR: 1.9 (1.0-4.8)), and how food was accessed (with those who purchased food from hospital canteens having an OR of 2.6 (1.1-6.1)) Purchasing food from the hospital canteen was one of the major sources of food for hospitalised patients This research found that most of the food consumed by patients in the hospital was self-provided including home-cooked (27.7%), bought from outside the hospital (13.6%), bought from the hospital canteen (16.8%), or a combination of these (39.4%).Only 1.3% of food was provided by the hospital, despite having better nutritional value compared

to other sources

To identify the patients most at risk of malnutrition, the validity of commonly used, and previously validated screening tools were explored within the Vietnamese context These screening tools were not necessarily applicable to the Vietnamese context due to differences in body composition, nutrition status, disease patterns, and healthcare systems The results show that the NRS-2002, MST combined with BMI (< 18.5kg/m2),and MUST showed moderate/fair validity compared to the reference method, Subjective Global Assessment (SGA or BMI < 18.5kg/m2) BMI alone at < 21kg/m2 had moderate validity, but was lower compared to other screening tools and could be used in circumstances where the resources are significantly constrained MST alone and MNA-SF showed poor validity due to low sensitivity (41.8% and 35.0% for MST and MNA-SF respectively)

The two most valid nutrition screening tools found in the study One,

NRS-2002 and MST combined with BMI, were assessed regarding their validity, reliability, and feasibility as administered by medical doctors NRS-2002 was selected because it showed the best values for areas under the curve (AUC), sensitivity, and specificity Both MUST and MST combined with BMI had similar values for AUC, sensitivity, and specificity However, MST combined with BMI was

vi Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools

selected because it requires less calculation for the percent of weight loss Thus, it is less burdensome for users Medical doctors have been designated by the Ministry of Health to carry out this screening The results indicated that both NRS-2002 and MST (combined with BMI) were valid, reliable, and feasible for use by medical doctors for nutrition screening in hospitals in the resource sparse Vietnamese context Additional activities are required to make nutrition screening more feasible, such as the provision of standard equipment for measuring weights and heights in hospitals, the development of nutrition screening protocol, and training for medical staff regarding nutrition screening

This research firstly confirms the current international evidence indicating that, regardless of the national income status and geographic location, malnutrition is a common issue among hospitalised patients in acute care settings and is associated with a range of clinical and personal factors and dietary intake

The results of this research also provide evidence and insights into areas for improvement within nutrition and dietetics services in hospitals in Viet Nam The identification of the high prevalence of hospital malnutrition and its related issues indicates the presence of significant under-estimated but modifiable issues that are present in most hospitals in Viet Nam, and that directly contribute to medical treatment outcomes This realisation contributes to a better awareness of the need to establish comprehensive and effective nutrition and dietetics systems in hospitals to provide nutrition care to optimise outcomes for all patients, not just those requiring therapeutic intervention The research also highlights that nutrition and dietetic intervention is required across the continuum of care prior to hospital admission, during hospitalisation, and after hospital discharge These findings show that appropriate consolidation and development of the nutrition workforce in Viet Nam in hospitals and other health care facilities and settings, as well as the development of guidelines, standards, and recommendations from health authorities are required Furthermore, by confirming the validity, reliability, and feasibility of highly validated screening tools, this research shows that BMI, a commonly used indicator for malnutrition in hospitals in Viet Nam, is not an optimal indicator for identifying the risk of malnutrition due to it slower sensitivity compared to that of other screening tools This study confirms that internationally recognised tools are

appropriate for use, specifically the NRS-2002 and MST combined with BMI (< 18.5kg/m2)

Finally, by providing evidence about the current inadequacy (low energy and nutritional value) of meals available to patients in hospital in Viet Nam via a dispersed and voluntary foodservice system and its association with malnutrition, this research shows that the foodservice systems in hospitals in Viet Nam are currently inappropriate In the short term, it is recommended that appropriate guidance be developed and distributed for all foodservice providers on hospital grounds In the long-term, hospitals will need to fully provide both normal and therapeutic meals for all patients as part of standard care to achieve the best treatment outcomes for patients This can be done by covering the cost of meals via universal medical insurance

Further research is indicated to explore the impact of infrastructure, resources, policies, and beliefs on the prevention and treatment of malnutrition in hospitals; to conduct intervention studies for the prevention and treatment of malnutrition utilising

a model hospital approach; to explore malnutrition with other patient groups, such as infants and children, pregnant women, patients admitted to emergency and rehabilitation departments, and in other health care settings; and finally, periodically conducting surveillance on this issue to improve the quality of nutrition and dietetics services in hospitals

This research found malnutrition to be a common issue for hospitalised patients, and that hospital foodservices have a role to play It is essential that Vietnamese hospitals improve foodservices to optimise nutrition interventions, improve outcomes, and reduce costs In addition, validated malnutrition screening tools developed in contexts very different to Viet Nam can be applied in the Vietnamese context, indicating that the development of new tools is not necessary These findings are potentially transferable to other lower middle-income countries in the Southeast Asia region

A Note Regarding Format

This dissertation is a thesis by published papers It contains four articles that have either been published or submitted for publication to journals; therefore, the wording and spelling of the journals are as published, and some contain American spelling The logical flow of the thesis is maintained by introducing these articles where they fit most appropriately into the thesis structure All articles have been reformatted using the indicated referencing styles from submitted journals and reconfigured to Word to provide consistent formatting throughout the thesis Moreover, tables and figures have been numbered continuously throughout the thesis, for consistency

Published or Submitted Manuscripts Resulting

from this PhD Research

Cuong, T Q., Banks, M., Hannan-Jones, M., Diep, D T N., & Gallegos, D

Prevalence and associated risk factors of malnutrition among hospitalised adults in

a multisite study in Ho Chi Minh City Viet Nam Asia Pac J Clin Nutr 2018;27(5):986-995

Cuong, T Q., Banks, M., Diep, D T N., & Gallegos, D., M., Hannan-Jones

(2018) Characteristics of dietary intake among adult patients in hospitals in a lower middle-income country in Southeast Asia Manuscript has been accepted for publication in Nutrition and Dietetics

Cuong, T Q., Banks, M., Hannan-Jones, M., Diep, D T N., & Gallegos, D

Validity of four nutritional screening tools against Subjective Global Assessment (SGA) for inpatient adults in a lower middle-income country in Asia. Eur J Clin Nutr

2018 Jun 12 doi: 10.1038/s41430-018-0217-8

Cuong, T Q., Banks, M., Hannan-Jones, M., Diep, D T N., & Gallegos, D

(2018) Validity, reliability and feasibility of nutrition screening tools NRS-2002 and MST administered by medical doctors Manuscript will be submitted for publication

Presentations Resulting from this PhD

Research

Abstracts accepted for oral/poster presentations

Cuong, T Q., Banks, M., Hannan-Jones, M., Diep, D T N., & Gallegos, D

Hospital malnutrition: Prevalence, aetiology and appropriate screening tools. At the

4thHo Chi Minh City Open Nutrition Conference Ho Chi Minh City Viet Nam Food and Nutrition Society of Ho Chi Minh City Viet Nam August 2015 (Oral presentation)

Cuong, T Q., Banks, M., Hannan-Jones, M., Diep, D T N., & Gallegos, D

Some characteristics of nutrition and dietetics services in hospital in Ho Chi Minh City Viet Nam At the 5thHo Chi Minh City Open Nutrition Conference Ho Chi Minh City Viet Nam Food and Nutrition Society of Ho Chi Minh City Viet Nam August

2016 (Oral presentation)

Cuong, T Q., Banks, M., Hannan-Jones, M., Diep, D T N., & Gallegos, D

The most appropriate nutrition screening tools for use in adults patients in hospitals

in Viet Nam At the 7thHo Chi Minh City Open Nutrition Conference Ho Chi Minh City Viet Nam Food and Nutrition Society of Ho Chi Minh City Viet Nam 27-28thJuly 2018 (Oral presentation)

xiv Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools

Invited speaker

Cuong, T Q., Developing standards for screening and assessment of nutrition

status of patients in hospitals in Viet Nam Workshop on training for organizing nutrition and dietetics activities that accordant to the quality standard for hospital Department of Health Ho Chi Minh City Viet Nam April 2016

Cuong, T Q., Developing and implementing nutrition screening tools for

hospital inpatients in Ho Chi Minh City. Workshop on review the results of practices related to nutrition and dietetics at the hospital Department of Health Ho Chi Minh City Viet Nam January 2017

Cuong, T Q., Nutritional screening and assessment for inpatients hospital in

Viet Nam Presented for medical staff at a number of hospitals in Ho Chi Minh City Viet Nam during 2016 and 2017 including: Tu Du gynaecology and obstetric hospital, Mekong gynaecology and obstetric hospital, Binh Dan surgery city level hospital, Traumatic and Orthopaedic city level hospital, Dong Nai general provincial hospital

Cuong, T Q., Nutritional screening and assessment for inpatients hospital in

Viet Nam Presented at the professional training courses for staff from Nutrition and Dietetics from hospitals in Ho Chi Minh City and other provinces in the Southern areas of Viet Nam On December 2016, April 2017 and September 2017

Table of Contents

Keywords i

Abstract iii

A Note Regarding Format ix

Published or Submitted ManuscriptsResulting from this PhD Research xi

Presentations Resulting from this PhD Research xiii

Table of Contents xv

List of Figures xxi

List of Tables xxiii

List of Abbreviations xxv

Statement of Original Authorship xxvii

Acknowledgements xxix

Chapter 1: Introduction 1

1.1 Background 1

1.2 Context 3

1.2.1 Research Context 3

1.2.2 Personal Context 5

1.3 Purposes 6

1.4 Significance, Scope and Definitions 7

1.4.1 Significance 7

1.4.2 Scope 7

1.4.3 Definitions 8

1.5 Thesis Outline 9

Chapter 2:Literature Review 11

2.1 Definitions and Terminologies 11

2.1.1 Definitions of Malnutrition 11

2.1.2 Terms Related to Malnutrition 11

2.2 Aetiology of Malnutrition in Hospitalised Patients 12

2.2.1 Personal Factors 14

2.2.2 Organizational Factors 18

2.3 Prevalence of Malnutrition in Hospitalised Patients 19

2.4 Consequences of Malnutrition in Hospitalised Patients 27

2.4.1 Physical Function Impairments 27

2.4.2 Psychological Impairments 28

2.4.3 Increased Morbidities 29

xvi Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools

2.4.4 Increased Hospital Length of Stay (LOS) 30

2.4.5 Other Consequences 30

2.5 Criteria for Defining Malnutrition in Hospitalised Patients 35

2.6 DiagnosticTools for Identifying Malnutrition 36

2.6.1 Anthropometry 37

2.6.2 Biochemical Measurements 41

2.6.3 Body Composition 41

2.6.4 Hand Grip Strength 42

2.6.5 Assessment Tools 43

2.6.6 Screening Tools 46

2.7 Characteristics of Hospital Meals 54

2.7.1 Roles of Hospital Meals 54

2.7.2 Development, Production and Distribution of Hospital Meals 54

2.7.3 Nutritional Value of Menus in Hospital 56

2.8 Theoretical Framework 57

2.9 Tool Validation 59

2.10 Lower Middle Income Countries in Southeast Asia Region 60

2.11 Socio-economic and Nutritional Status of Vietnamese Population 62

2.12 Hospital System and Nutrition-dietetics Services in Hospitals in Viet Nam 65

2.12.1 Hospital System in Viet Nam 65

2.12.2 Nutrition and Dietetic Services in Viet Nam 67

2.13 Existing KnowledgeGaps 69

Chapter 3:Research Design 73

3.1 Study Design 73

3.2 Study Population and Setting 73

3.2.1 Reference Population 73

3.2.2 Source Population 74

3.3 Sampling Design 75

3.3.1 Study One and Two 75

3.3.2 Study Three 78

3.4 Subject and Recruitment 79

3.4.1 Study One and Two 79

3.4.2 Study Three 80

3.5 Measurements 81

3.5.1 Study One and Two 81

3.5.2 Study Three 83

3.6 Data Collection 84

3.6.1 Study One and Two 84

3.6.2 Study Three 86

3.7 Data Analysis 88

3.7.1 Study One and Two 88

3.7.2 Study Three 92

3.8 EthicalConsiderations 93

Chapter 4:Prevalence and Associated Risk Factors 97

4.1 Introduction 97

4.2 Statement of Contribution of Co-authors 98

4.3 Paper 1 99

4.3.1 Introduction 101

4.3.2 Material and Method 102

4.3.3 Results 105

4.3.4 Discussion 107

4.3.5 Acknowledgments 111

4.3.6 Conflict of Interest Statement 111

4.3.7 References 112

4.3.8 Figures and Tables 117

4.4 Conclusion 125

Chapter 5:Characteristics of Dietary Intake 129

5.1 Introduction 129

5.2 Statement of Contribution of Co-Authors 130

5.3 Paper 2 131

5.3.1 Introduction 133

5.3.2 Material and Methods 134

5.3.3 Results 137

5.3.4 Discussion 138

5.3.5 Funding source 141

5.3.6 Conflict of Interest Statement 141

5.3.7 References 142

5.3.8 Figures and Tables 144

5.4 Conclusion 148

Chapter 6:Validity of Nutrition Screening Tools 151

6.1 Introduction 151

6.2 Statement of Contribution of Co-authors 152

6.3 Paper 3 153

6.3.1 Introduction 155

xviii Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools

6.3.2 Material and Methods 156

6.3.3 Results 159

6.3.4 Discussion 160

6.3.5 Acknowledgments 161

6.3.6 Conflict of Interest Statement 162

6.3.7 Reference 162

6.3.8 Figures and Tables 165

6.4 Conclusion 170

Chapter 7:Feasibility of Screening Tools 171

7.1 Introduction 171

7.2 Statement of Contribution of Co-authors 172

7.3 Paper 4 173

7.3.1 Introduction 175

7.3.2 Material and Methods 176

7.3.3 Results 179

7.3.4 Discussion 181

7.3.5 Conclusion 183

7.3.6 Acknowledgments 184

7.3.7 Conflict of Interest Statement 184

7.3.8 References 184

7.3.9 Figures and Table 188

7.4 Conclusion 195

Chapter 8:Conclusions 197

8.1 Summary of Key Outcomes 198

8.2 Significance of Outcomes 201

8.2.1 Confirmation of Current International Evidences 201

8.2.2 Provide New Evidences for Viet Nam 201

8.3 Recommendations 204

8.3.1 Short-term Recommendations 205

8.3.2 Long-term Recommendations 209

8.3.3 Recommendations for Further Research 211

8.4 Strengths and Limitations 212

8.5 Concluding Statements 213

Bibliography 215

Appendices 239

1 Questionnaire Used in Study One and Two (English) 240

2 Questionnaire Used in Study One and Two (Vietnamese) 247

3 Questionnaire Used in Study Three (English) 254

4 Questionnaire Used in Study Three (Vietnamese) 247

5 The Nutrition Risk Screening (NRS-2002) 278

6 The Malnutrition Screening Tool (MST) 279

7 The Malnutrition Universal Screening Tool (MUST) 280

8 The Mini Nutrition Assessment Short Form (MNA-SF) 281

9 Food Booklet Usedin theDietary Intake Interview 282

10 Photo of Sample of UtensilsUsed in This Research 283

List of Figures

Figure 1-1: Outline of the chapters in the thesis 10 Figure 2-1: Etiological diagram of malnutrition in hospitalised patients 13 Figure 2-2: Inflammation response in medical conditions 15 Figure 2-3: Factors influencing the food choices 17 Figure 2-4: Diagram showing consequences of malnutrition in hospitalised patients34 Figure 2-5: Nutrition care process and model 58 Figure 2-6: Diagram of burden of healthcare system from the increase of NCDs 61 Figure 2-7: Map of district and zone of Ho Chi Minh City, Viet Nam 67 Figure 3-1: The relationship between research questions, studies, research aims and related papers 74 Figure 3-2: Sampling flowchart 78 Figure 3-3: Cross-cultural adaption process for translation of a questionnaire 85 Figure 3-4: Diagram of three studies in this research project 95 Figure 4-1: Sampling flowchart 124 Figure 4-2: Diagrammatic summary of hospital malnutrition prevalence and

associated risk factors 125 Figure 4-3: Summary of the Chapter 4 127 Figure 5-1: Summary of the chapter 5 149 Figure 6 1: Percent of underweight (BMI<18.5mg/m2) against SGA groups 169 Figure 7-1: Data collection flowchart 194 Figure 8-1: Summary of the research project 214

List of Tables

Table 1-1: Research questions and aims 6 Table 2-1: Prevalence of malnutrition in hospitalised adults in Australia and

European countries 23 Table 2-2: Prevalence of malnutrition in hospitalised adults in Latin American countries 25 Table 2-3: Prevalence of malnutrition in hospitalised adults in Asian countries 26 Table 2-4: Prospective studies on consequences of malnutrition in hospitalised patients 32 Table 2-5: Validated international screening tools 50 Table 2-6: BMI cut-off values used in different guidelines, diagnostic tools and studies in clinical setting 51 Table 2-7: Calculation of sensitivity, specificity, positive predictive value and

negative predictive value 60 Table 3-1: Participants inclusion and exclusion criteria 76 Table 3-2: Number of participants required at each hospital level 77 Table 3-3: List of variables and their types, categories and derived 91 Table 4-1: Information about the hospitals in the survey 117 Table 4-2: Demographic characteristics of hospitalised adults 118 Table 4-3: Clinical characteristics of malnutrition among hospitalised adults 119 Table 4-4: Weighted prevalence of malnutrition by demographic and clinical

characteristics using (SGA or BMI) as diagnostic criteria 120 Table 4-5: Associations between malnutrition (SGA or BMI) and potential correlates among hospitalised adults 122 Table 5-1: General characteristics and catering services of six hospitals 144 Table 5-2: Energy and nutritional values of meals, meal source main reason for low dietary intake of participants during hospitalization by nutritional status 145

xxiv Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools

Table 5-3: Association between low dietary intake (<50% of requirement) and potential correlates among hospitalised adults 147 Table 6-1: Details on the criteria used in screening tools and modified screening tools used in this study 165 Table 6-2: Characteristics related to malnutrition among hospitalised adults by nutritional status 166 Table 6-3: Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and percentage of correctly classified measures of the nutrition screening tools and nutritional parameters using (SGA or BMI) as a

reference method 168 Table 6-4: Weighted malnutrition risk among hospitalised patients using different criteria 170 Table 7-1: Background characteristic of participants in the validity study 188 Table 7-2: Characteristics of participants in reliability and feasibility studies 189 Table 7-3: Validity and reliability of NRS-2002 and MST+BMI using SGA or BMI

as reference method administered by medical doctors 190 Table 7-4: Responses on the benefit and role of nutrition screening among medical doctors 191 Table 7-5: Response on the acceptability and feasibility of screening tools among medical doctors 192

List of Abbreviations

ASPEN: American Society for Parenteral and Enteral Nutrition

COPD: Chronic Obstructive Pulmonary Disease

ESPEN: European Society for Parenteral and Enteral Nutrition

FFMI: Fat Free Mass Index

ICD 10 : International Classification of Diseases version 10

MNA: Mini Nutrition Assessment

MNA-SF: Mini Nutrition Assessment – Short Form

MST: Malnutrition Screening Tool

MUST: Malnutrition Universal Screening Tool

NPV: Negative Predictive Value

PPV: Positive Predictive Value

QUT: Queensland University of Technology

NRS-2002: Nutrition Risk Screening 2002

SGA: Subjective Global Assessment

WHO: World Health Organization

Statement of Original Authorship

The work contained in this thesis has not been previously submitted to meet requirements for an award at this or any other higher education institution To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made

Acknowledgements

Firstly, I would like to offer my sincere thanks to the participants who agreed

to participate in this research These participants were enthusiastic, gave their valuable time, and provided important personal information while facing the difficulties caused by illness, and in some cases, serious illness I wish you all well and promise to turn your contributions into useful applications that will benefit other patients I would also like to thank the hospital leaders and medical staff, especially the staff of the Nutrition and Dietetics Departments at the hospitals where I went to collect data Your enthusiasm and the time you spent helping me with data collection

or as research participants is greatly appreciated

My deepest thanks go to my supervisory team, Professor Merrilyn Banks, Dr Mary Hannan-Jones, Professor Do Thi Ngoc Diep, and especially, my principal supervisor, Professor Danielle Gallegos Although busy with a lot of work, all of you, with your kindness, enthusiasm, expertise, and responsibility, have guided, taught, supported, and motivated me throughout my journey You have made my journey smooth, happy, and memorable, with a variety of useful activities and beautiful memories Your methods will be the standards I will follow in the pathway for my professional career in the future

Next, I would like to thank the Australian Government for providing me with this PhD scholarship, without it, my dream would not have come true I would like to thank the leaders of Ho Chi Minh City People's Committee, the Ho Chi Minh City Department of Health, and the Director of the Nutrition Centre for allowing me to study I sincerely thank the Director, leaders of departments, and my colleagues at the Nutrition Centre, especially in the General Planning Department, who encouraged me, took over my other tasks, and assisted me in data collection over the last three years Without all of you, my journey would have been much harder

I am also very grateful to the staff from the QUT Health Research Services, Student Support Services, especially Ms Emma Kirkland, Mrs Zia Song, and Mrs Alina Sarosiek, for your strong support for both academic and life issues; Dr Ekta Agarwal, my supervisor at an early stage, who helped me to develop the protocol; Dr Martin Reese, from the Academic Language and Learning Service, who assisted me

xxx Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools

with English editing; professional editor, Ms Kylie Morris, who provided copyediting and proofreading services for the non-publication chapters of this thesis, according to university-endorsed guidelines and the Australian Standards for editing research theses; Dr Edward Gosden, who helped me with statistics and data analysis issues; Professor Susan Ash, Professor Do Van Dung, Dr Maree Ferguson, Dr Ta Thi Lan, Dr Vu Quynh Hoa, Dr Vo Thi My Dung who provided valuable comments about the protocol when attending or playing a role as panel members at the confirmation seminar in Australia or the protocol review seminar in Viet Nam; and all of my Vietnamese and Australian friends who shared all of these memorable moments with me during my time studying and living at QUT, Brisbane, Australia Last but not least, I would like to thank all of the members of my big family,

my mother, Nguyen Thi Hong Mai; my father, Tran Thanh Danh; my father-in-law, Tran Minh Sang; my mother-in-law, Ho Thi Suoi; my sons, Tran Quoc Minh and Tran Quoc Khoa; my sister, Tran Thi Hong Loan and her family; my sisters and brothers-in-law and their families; and especially my most beloved, my wife, Tran Thi Minh Ha All of you, with your endless love, encouragement, great sacrifice, and sharing of the household and parenting tasks, have helped me to spend time, and to focus on writing, travel, and successfully complete my studies Your love has been, and will be, a great motivation for me to overcome all of the difficulties in my study, work, and life Please accept my forever love for all of you!

Chapter 1: Introduction

This chapter outlines the background (Section 1.1), context of the research (Section 1.2), and research purpose (Section 1.3) Section 1.4 describes the significance and scope of this research and provides definitions of the terms used Finally, Section 1.5 includes an outline of the remaining chapters of the thesis

Malnutrition in hospitalised patients is a common problem worldwide, especially among those with chronic or severe diseases (1) The prevalence of malnutrition in adults in acute care setting varies from 20.0% to 50.0%, depending

on medical disciplines, nutritional status before admission, disease pattern, age structure, treatment options, nutrition and dietetic services, and the criteria used for diagnosis (1-3) Regarding medical disciplines, hospital malnutrition is more prevalent among oncology, geriatric, gastroenterology, respiratory, and nephrology inpatients (4, 5) Hospital malnutrition is an issue of concern, as it is associated with numerous adverse outcomes during hospitalisation (1, 2)

In Viet Nam, hospital malnutrition has been measured in some hospitals, with the prevalence varying from 33.3% to 55.7%, depending on the patient population and diagnostic criteria (6-9) However, most of these studies were carried out in single hospitals and were not representative of the general hospital population To date, there has been no national or city survey on the nutritional status of individuals

in hospitals in Viet Nam

Hospital malnutrition has been associated with higher rates of hospital infection (10); medically-related complications (11); muscle and fat loss (12); pressure ulcers (13, 14); impaired wound healing (15); longer length of hospital stay, leading to higher associated costs (16); and higher mortality rates (2, 17, 18) Malnutrition can be caused by a range of factors, including low dietary intake (19), poor nutrient absorption, excessive nutrient losses, disease-related metabolic alterations, or a combination of the above factors (20) These effects have been seen within inpatient populations regardless of the country of study

2 Chapter 1: Introduction

With these significant adverse effects, promptly identifying patients at risk of malnutrition after admission for further treatment is a priority for hospitals Due to the large number of patients and limited resources in hospitals, nutrition screening is undertaken to identify patients at risk of malnutrition for further detailed assessment Nutrition screening should be conducted using validated screening tools and be simple enough to enable it to be implemented by general non-nutrition hospital staff (21, 22) According to hospital best practice, all patients should be screened for malnutrition within 24 hours of admission, and this should be followed by nutritional assessment and a nutrition intervention plan for inpatients identified as at risk (21)

In most high-income countries, nutritional screening has become a routine part of the medical history collected upon admission In high-income countries, a variety of validated screening tools are currently recommended for use in acute care settings, such as the Nutrition Risk Screening 2002 (NRS-2002), Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST),and Mini Nutrition Assessment Short-Form (MNA-SF) (2, 23-25) Nutrition screening is a crucial step for bringing patients into the nutrition care process, a widely accepted evidence-based model of patient centred nutrition care that involves assessment, diagnosis, intervention, monitoring and evaluation steps (26) Nutrition care during hospitalisation can help to improve physical function, reduce complications of diseases, accelerate recovery, and reduce hospital resources use (22)

Following the identification of hospital malnutrition, interventions ranging from nutrition counselling, oral nutritional supplements, and enteral and parenteral feeding should be implemented for malnutrition prevention and treatment In most high-income countries, all meals are provided by hospitals as part of standard care (27) As such, the cost of meals is included in hospital fees and covered by subsidies from the government or by medical insurance For food safety reasons, bringing food

or meals from outside the hospital setting is not usually recommended and guided by hospital management to protect patients from adverse events In general, menus developed for hospital meals are governed by jurisdiction or national menu and/or nutrition standards (or policies) to ensure patients’ nutrition needs are met (28)

1.2 CONTEXT

1.2.1 Research context

Since 1998, the admission of inpatients into hospitals in Viet Nam has increased by five percent each year, from seven billion admissions in 1998 to 24 billion admissions in 2006 (29) This can be explained by an increase in total population, and in particular, a rapid increase in the older age group and changes in disease patterns During this time, there has been a decrease in patients presenting with communicable diseases and an increasing number of presentations of patients with non-communicable chronic diseases (NCDs)in Viet Nam The percentage of communicable diseases decreased from 55.5% in 1976 to 25.2% in 2008, and NCDs increased from 42.7% in 1976 to 63.1% in 2008 The percentage of admissions due

to injuries, accidents, and poisoning has been stable (10%) (30) With respect to mortality patterns, 75% of deaths in Viet Nam in 2010 were caused by NCDs, 13% from accidents and injuries, and 12% from communicable diseases (30)

In addition to an increasing number of hospital admissions, the complexity of medical procedures able to be undertaken in Viet Nam has also increased There have been significant achievements in health care and medical services in Viet Nam through appropriate government resourcing in recent years Several sectors now perform a range of sophisticated medical interventions, including those related to organ transplants, cardiovascular/oncology interventions, endoscopic/robotic surgery, application of stem cells for trauma/orthopaedic intervention, assisted reproduction, ophthalmology, traditional medicine, and vaccine and medical biological products production (31) While there have been gains made in improving medical services and infrastructure, hospitals now receive less financial support from the government

The financial autonomy of public hospitals has been a major policy initiative of the Vietnamese Government since 2006,as presented in Decree number 43/2006/NĐ-CP(32) This means hospitals rely on revenue from medical insurance reimbursements and hospital fees without subsidisation from the government The government has instead focused on fully paying or subsidising medical insurance for students, members of the military, some government officers, retired workers, people with merit (with government certification), and socially vulnerable groups, such as those in poverty or marginal poverty households, and those belonging to ethnic

4 Chapter 1: Introduction

minorities living in low socio-economic status areas as stated in the Viet Nam Medical Insurance Law 2014(33) In 2016, the Vietnamese government set new targets for achieving universal coverage of public health insurance from 81.3% to 90.7% by 2020 as stated in the Decision 1167/QĐ-TTg on 28th June 2016 of Prime Minister Viet Nam(34) These targets will be met by requiring employers and employees to contribute to medical insurance (4% from employers and 2% from employees), and encouraging others (for example self-employees) to buy medical insurance on a voluntary basis (35) Public hospitals throughout the country are taking a stepped approach and have converted to this new financial scheme(36) Since the1st October 2017, 100% of public hospitals in Ho Chi Minh City(HCMC) are now required to be financially autonomous for staff salaries and daily expenses The government will support budgets for investment on infrastructure and major medical equipment According to the announcement from the Ministry of Health Viet Nam, the government will take a stepwise approach to providing meals for patients, with these funded via this new universal health insurance

In this context, hospitals are constantly finding ways to maximise their efficiency, including reducing the length of stay, maximising treatment outcomes from complex medical procedures, and improving the satisfaction of patients during their hospitalisation It should be noted due to the lack of a robust primary health care system a majority of patients with acute and chronic conditions are seen in the hospital system rather than in the community Improving the quality of nutrition care

is also seen as a good solution Therefore, nutritional care in hospitals in Viet Nam has recently received more attention and is now regulated by Ministry of Health, as stated in two documents issued by the Minister of Health, Viet Nam: “Circular 08: Guidelines on nutrition and dietetic services in hospital”, issued in January 2011 (37) and “Criteria Set for Evaluation of Hospital Quality”, issued in 2013 (first edition) and 2016 (second edition) (38)

In the last five years these government regulations have resulted in a significant number of hospitals establishing nutrition and dietetics departments Hospital audit records from the Nutrition Centre, HCMC show that over 90% of hospitals in HCMC have established a nutrition and dietetics department or team(39) However, the quality of services provided by the majority of these nutrition and dietetics departments is still limited

The establishment of nutrition and dietetic services in hospitals in Viet Nam is relatively new and poorly resourced(40) The government has developed and disseminated preliminary instructions and guidelines to guide activities; however, these remain limited Hospital leaders have poor understanding about the importance

of nutrition and dietetics in their facilities and it remains a low priority The nutrition workforces operating within hospital settings have been mobilised from other disciplines (such as medical doctors and nursing staff) in the hospitals In addition to health system infrastructure factors, differences in the food and nutrition-related knowledge, beliefs, concerns, and practices of the Vietnamese population potentially impact the aetiology of hospital malnutrition

Nutrition interventions to alleviate hospital malnutrition in Viet Nam, such as the provision of hospital meals, are currently neither routinely provided by hospitals nor covered by public medical insurance(33) Patients are required to make provisions for their own meals, including preparing food and covering the costs of their food and beverages during their hospitalisation Apart from limited hospital foodservices, common sources of foods for patients are home-cooked meals brought into the hospital (by relatives), or foods purchased from hospital canteens (low cost retail outlets for patients, families and staff) and take-away food outlets (located outside the hospital grounds) In some cases, charitable organisations arrange for food provisioning either on or off the hospital site At present, guidance for preparing, buying or cooking foods/meals is provided only for conditions or situations that require special nutrition attention, for example, patients requiring nasogastric feeding It is unclear whether the dietary requirements for hospitalised patients in Viet Nam are being met Furthermore, no nutrition screening tools for hospitalised patients have been developed, validated, or recommended for use in Viet Nam

1.2.2 Personal context

It is important in any research to be transparent about the background and experience of the researcher In this instance, the PhD candidate is a Vietnamese-trained medical doctor with a Masters of Medical Sciences from Australia Since graduation from medical school, the candidate has worked for the Nutrition Centre, HCMC, Viet Nam, undertaking nutrition counselling for individuals, implementing

6 Chapter 1: Introduction

school-based and community-based nutrition research and interventions, as well as teaching and supervising students from several universities

The Nutrition Centre is one of only two government research institutes specific

to nutrition in Viet Nam; the other is the National Institute of Nutrition located in Ha Noi, the capital of Viet Nam The Nutrition Centre, HCMC has approximately 100 staff, and is responsible for implementing the National Nutrition Strategy at HCMC and an additional five national nutrition programs in HCMC(41); providing nutrition counselling and treatment at its clinic; providing nutrition education and communication for different population groups; conducting research in nutrition; providing training and continuous education for staff of nutrition and dietetics departments from hospitals and medical centres in HCMC and other southern provinces; and assembling evidence and advising about nutrition-related policies for the Health Department of HCMC and the Ministry of Health In the last few years, the Nutrition Centre, HCMC has been involved in the development of guidance for nutrition screening, assessment, and intervention for hospital malnutrition

1.3 PURPOSE

The research questions, with the corresponding research aims of this research are presented in Table 1-1

Table 1-1: Research questions and aims

Research question 1: What are the

prevalence and associated risk

factors of malnutrition in

hospitalised adults in Viet Nam?

1 Determine the point prevalence of malnutrition in hospitalised adults

2 Identify the factors associated with malnutrition among hospitalised adults

Research question 2: What is the

most feasible method for identifying

malnutrition in hospitalised adults in

Viet Nam?

3 Determine the most appropriate screening tool for use in risk identification and monitoring in Viet Nam

4 Test the performance of the tool in the Vietnamese hospital context

Research question 3: What are the

characteristics of patient meals

consumed in hospitals and their

association with malnutrition?

5 Determine the relationship between meal characteristics and malnutrition

in hospitals in HCMC Viet Nam

1.4.1 Significance

This research aims to provide important initial information for health care authorities in HCMC, and potentially across Viet Nam The data will help to identify the magnitude of malnutrition among adults during hospitalisation, the groups of patients who are at higher risk of malnutrition, and the most appropriate nutrition screening tools for use within the hospital setting given the current infrastructure restraints The research aims to provide evidence about the provisioning and importance of hospital meals The findings will therefore help to establish and inform current and future policies in terms of nutrition screening of hospitalised patients, as well as the organisation and management of foodservices in hospitals The information also contributes to the understanding of hospital systems and malnutrition in hospitalised patients in lower middle-income countries in the Southeast Asia region

Nationally, there are similarities with respect to health care systems, culture, beliefs, socioeconomic status, and population prevalence of malnutrition in most large cities in Viet Nam It is therefore anticipated that the results from this research will be able to be extrapolated and applied across Viet Nam

There are some similarities regarding body composition, culture and socioeconomic status between Viet Nam and some lower middle income countries in South East Asia, therefore the findings from this research could be extended to these countries However, variations in healthcare systems and infrastructure, nutritional status of the population and the nutrition-related policies from governments are unknown and may be a barrier to implementation

1.4.2 Scope

This research focuses only on malnutrition among adults who are hospitalised and receive acute care This is because there has been a rapid increase in non-

8 Chapter 1: Introduction

communicable diseases and an aging population increasing the risk of malnutrition The research focuses on acute care, as this is the most common care setting in Viet Nam Rehabilitation, residential aged care, and community care are not currently common in Viet Nam

Paediatrics, pregnant women, and patients in intensive care unit (ICU) were deemed to be outside of the scope of this research due to the differences in the criteria used to identify malnutrition risk in these populations

1.4.3 Definitions

In general, malnutrition is defined as “a state of nutrition in which a deficiency

or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition), body function and clinical outcome” (42) (p.3)

Malnutrition can present as either under- or over-nutrition in different settings, such as in the general population; or in medical care sites, such as acute care, rehabilitation, residential aged care, and community care However, this research focuses only on patients in acute care in hospital settings In this document, malnutrition mainly refers to under-nutrition

More specifically, the progress of, as well as specific factors contributing to, the pathophysiology of disease-related malnutrition were clarified in the definition from the American Society for Parenteral and Enteral Nutrition (ASPEN) According

to ASPEN, malnutrition is “an acute, subacute or chronic state of nutrition, in which varying degrees of over-nutrition or under-nutrition with or without inflammatory activity has led to a change in body composition and diminished function” (21) (p.16)

With the development of better understanding and evidence regarding

malnutrition in hospitalised patients, sets of diagnostic criteria for malnutrition in

adults have been developed and proposed by two organisations specialising in nutrition: the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (ASPEN) and the European Society for Parenteral and Enteral Nutrition (ESPEN) According to the ASPEN, subjects are diagnosed with malnutrition if they have two or more of the following six characteristics (43):

- insufficient energy intake;

- weight loss;

- loss of muscle mass;

- loss of subcutaneous fat;

- localised or generalised fluid accumulation that may sometimes mask weight loss; and

- diminished functional status as measured by hand grip strength

According to ESPEN, before diagnosis of malnutrition is considered it is mandatory to fulfil criteria for being “at risk” of malnutrition using a validated risk-screening tool There are two ways to diagnose malnutrition: (44)

- Body mass index (BMI)<18.5 kg/m2 ;

- weight loss (unintentional) > 10% indefinite of time, or >5% over the last 3 months combined with either BMI <20 kg/m2 if <70 years of age, or <22 kg/m2 if ≥ 70 years of age or Fat Free Mass Index (FFMI) <15 and 17 kg/m2 in women and men, respectively